Where Are We Now?
Chronic Achilles tendon tears are remarkably common, but their management is technically demanding, results can be unpredictable, and complications following reconstruction are frequent. Classic treatment options include turn-down flaps and extensive reconstructions, and even thoughtfully planned and well executed procedures may fail to restore the patient to full function [4]. These reconstructions should be protected from weight bearing and early ROM unless the construct is sufficiently strong to withstand the loads associated with early motion and loading. In this respect, therefore, turndown flaps are not the best option because the tendon that would be part of the reconstruction is itself affected by degenerative processes [3]. Though the gap between the retracted stumps is bridged with a turndown flap, the tissue used is not of ideal quality. The large surgical exposure necessary for such procedures also may be associated with a higher risk of skin complications and infection [7].
Where Do We Need To Go?
A double-free semitendinosus tendon allograft addresses many of these issues, but the construct is expensive, not widely available, and allograft tissue reconstructions raise concerns about infection, as well as late attenuation or rupture [2]. The semitendinosus tendon can be harvested easily from the ipsilateral popliteal fossa [5]. My group found that this approach can reliably restore function and reduce pain, though the procedure is technically demanding [6]. Should the ipsilateral semitendinosus tendon be insufficient, then the tendon of gracilis can be harvested through the same popliteal fossa incision, and used to further supplement the construct.
Early mobilization and loading have been proven to benefit tendon healing [1]. Recently, we have explored, with some success, the use of free tendon grafts as a treatment option because the ipsilateral gracilis and semitendinosus tendons are available, and can be used for this purpose [5]. A number of important questions remain, though, including: (1) What is the best available autograft? (2) Are autografts and allografts equivalent? (3) Can patients with reconstructed chronic tears be rehabilitated using the active protocols presently in use in patients with acute tears?
How Do We Get There?
Given the availability of different techniques and the fact that even tertiary referral centers may not collect enough patients, the technical skills to reliably perform such demanding reconstructions can be hard to acquire. Therefore, randomized controlled trials may not be realistically possible. A more pragmatic approach is to undertake a reasonable cluster of randomized multicenter trials with strict quality control supervision and periodic assessment of homogeneity of the surgical techniques and postoperative rehabilitation regimens.
Footnotes
This CORR Insights® is a commentary on the article “Is Dual Semitendinosus Allograft Stronger Than Turndown for Achilles Tendon Reconstruction? An In Vitro Analysis” by Aynardi and colleagues available at: DOI: 10.1007/s11999-017-5410-x.
The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or The Association of Bone and Joint Surgeons®.
This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-017-5410-x.
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